Hemorrhagic Conversion Research Articles

THE EFFICACY AND SAFETY OF USING PHENYLEPHRINE TO OPTIMIZE CEREBRAL PERFUSION IN DELAYED NEURO-INTERVENTION OF ACUTE ISCHEMIC STROKE

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Permissive hypertension (HTN) in the management of acute ischemic stroke (AIS) is not novel but a more recent approach considers the use of vasopressors to optimize cerebral perfusion pressure in the normotensive patient. CASE PRESENTATION: A 67-year-old female, active smoker with no medical history, presented with difficulty speaking for 6 hours. Exam revealed expressive aphasia with no other neurologic deficits. CT angiogram head showed abrupt cut-off of the distal M1 segment extending to the middle cerebral artery (MCA) bifurcation and proximal M2 vessels consistent with thromboembolism. Labs including cardiac enzymes were unremarkable. Cerebral angiogram showed high-grade sub occlusive stenosis of cervical left internal cerebral artery (ICA) and left MCA. She was admitted to the intensive care unit and placed on aspirin and clopidogrel. A systolic blood pressure (SBP) goal of 160-180mmHg was achieved using normal saline and phenylephrine (PE) infusions. 72 hours later she underwent successful percutaneous transluminal carotid artery angioplasty and stenting of the left ICA stenosis with subsequent complete resolution of her symptoms. PE was discontinued with new goal of SBP 100-120mmHg. Three days later she had acute onset chest pain. ST depressions in anterolateral leads on electrocardiogram and elevated cardiac enzymes prompted coronary angiography, which showed triple vessel disease requiring coronary artery bypass grafting. DISCUSSION: A U-shaped relationship exists regarding morbidity and mortality in SBP control in AIS. Elevated SBP increases risk of brain edema and hemorrhagic conversion while low pressures cause decreased central perfusion pressure leading to decreased collateral circulation to ischemic areas. In a 2001 pilot study using PE in patients with AIS, beyond the window of systemic thrombolysis, 54% of patients had improved NIH stroke scale (NIHSS) after achieving target SBP (160 mmHg or increase by 20% of admission SBP without exceeding 200 mmHg); no systemic or neurologic complications were reported.(1) A randomized trial (RT) utilizing PE to target an elevated SBP showed a short-term improvement in the NIHSS, cognitive score, and volume of hypoperfused tissue, when compared to the control group, in individuals with subacute and AIS.(2) In a multicenter RT of patients with noncardioembolic AIS, ineligible for revascularization therapy, PE was used to increase SBP up to 200 mmHg. 88.2% of patients in the intervention group exhibited improvements in NIHSS scores of ≥2 points; safety outcomes did not significantly differ between groups.(3) Our patient had complete resolution of neurologic symptoms after PE use and neuro-intervention, which preceded a cardiac event. CONCLUSIONS: While evidence exists to support the efficacy and safety of PE for SBP augmentation in the setting of AIS, larger studies with emphasis on safety are needed, as currently no guidelines exist. Reference #1: Rordorf G., Koroshetz W.J., Ezzeddine M.A., Segal A.Z., Buonanno F.S. A pilot study of drug-induced hypertension for treatment of acute stroke. Neurology. 2001 May 8;56(9):1210-3. doi:10.1212/wnl.56.9.1210 Reference #2: Hillis A.E., Ulatowski J.A., Barker P.B., et al. A pilot randomized trial of induced blood pressure elevation: effects on function and focal perfusion in acute and sub acute stroke. Cerebrovasc Dis. 2003;16(3):236-246. doi: 10.1159/000071122 Reference #3: Bang O.Y., Chung J.W., Kim S.K., et al. Therapeutic-induced hypertension in patients with noncardioembolic acute stroke. Neurology. 2019 Nov 19;93(21):e1955-e1963. Epub 2019 Oct 23. doi: 10.1212/WNL.0000000000008520. DISCLOSURES: No relevant relationships by Kyle Foster, source=Web Response No relevant relationships by Nisha Gandhi, source=Web Response No relevant relationships by Matthew Tavares, source=Web Response

S2317 ERCP-Associated Air Embolism, Bacteremia, and Septic Cerebral Infarction

INTRODUCTION: Rare complications of endoscopic retrograde cholangiopancreatography (ERCP) are duodenal perforation, necrotizing pancreatitis, systemic air embolism (AE), and septic cerebral infarction. We present a case of ERCP associated AE, bacteremia, and septic cerebral infarction in one patient that survived. CASE DESCRIPTION/METHODS: A 52-year-old female with a history of choledocholithiasis, ERCP lithotripsy and stent placement 1 month prior, presented for outpatient ERCP and underwent stent removal, duct dilation and removal of multiple stones. Immediately post procedure, she became unresponsive with supraventricular tachycardia and hypotension requiring ICU admission and intubation. A stat EKG showed diffuse ST elevations with near complete resolution on repeat EKG 20 minutes later. Additionally, a stat abdominal CT showed portal venous gas confirming the presence of an AE (Figure 1). However, troponins eventually rose to 17 ng/mL, thus heparin was started until NSTEMI could be ruled out. Empiric antibiotics were also started due to persistent hypotension and infectious workup ensued. Urgent cardiac catheterization showed non-occlusive disease, and heparin was stopped. Her blood cultures grew Enterobacter hormaechei, thought to have seeded during ERCP, and antibiotics were streamlined. Despite hemodynamic improvement, she had difficulty awakening from sedation and a subsequent brain MRI revealed bifrontal hemorrhagic emboli, likely septic due to involvement of various vascular territories and known ERCP-associated bacteremia. Furthermore, there was no pneumocephalus, ruling out cerebral AE, and no vegetation on transesophageal echo, ruling out endocarditis. DISCUSSION: AE may be confused with an anesthetic side effect or acute ischemic event. It should be considered with sudden clinical deterioration during or immediately after ERCP. The diagnosis is often made post-mortem, thus clinical suspicion is paramount and may be confirmed after visualizing air in the vena cava, portal vein, heart, or brain. Air can be absorbed rapidly thus diagnosis can be made on clinical suspicion alone. Air insufflation into the portal vein can occur during sphincterotomy and use of CO2 can minimize risk of AE. Anticoagulation is not indicated and treating NSTEMI may have allowed for hemorrhagic conversion of septic emboli, which are already prone to hemorrhage. Septic cerebral emboli from ERCP are exceedingly rare, with a handful of reported cases. Our case urges awareness of potential catastrophic sequela of ERCP.Figure 1.: Abdominal CT without contrast demonstrating the peripheral pattern of portal venous gas (arrows) as well as the central gas pattern of pneumobilia (ellipse).Figure 2.: Coronal abdominal CT demonstrating air in the portal venous system.

UTILITY OF PREDICTIVE SCORES FOR POST TPA INTRACRANIAL HEMORRHAGE IN ACUTE ISCHEMIC STROKES TO OPTIMIZE 24-HOUR POST TPA SCAN UTILIZATION

SESSION TITLE: Critical Care Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: The risk of symptomatic ICH status post tPA is variable but ranges from 2-7%. The consensus from AHA/ASA guidelines in 2018 recommend a follow up CT scan 24 hours after IV tPA, which was a component of the original NINDS tPA study. However, there is increasing evidence that the scans themselves may be unnecessary. Several scoring scales have been developed to determine which patients are at highest risk after receiving tPA. Determining the most useful scoring scale to stratify the risk of ICH may help avoid a 24 hour follow up scan. METHODS: A retrospective review of 519 consecutive acute ischemic stroke patients who received tPA at multiple hospitals in central Texas from February 2014 to January 2019. The data was gathered through chart review utilizing a data collection form that contained pertinent baseline characteristics and relevant clinical findings. Established predictive scores, RICH, THRIVE, SEDAN, were included in the data sheet. Median and IQR (inter quartile range) is reported as data showed non normal distribution. P-value is derived from Mann Whitney U test, comparing the median score (THRIVE, SEDAN, RICH) between two groups. RESULTS: Our study included a population total of 492 patients. For patients with symptomatic intracranial hemorrhage (sICH), median scores were as follows: THRIVE 4.50 (p < 0.001), SEDAN 2.00 (p < 0.001) and RICH 3.00 (p = 0.1343). Additionally, the odds ratio for symptomatic intracranial hemorrhage were as follows: THRIVE 1.48 (p < 0.001), SEDAN 1.88 (p < 0.001) and RICH 1.27 (p = 0.1291). C-statistic for THRIVE was 0.72(,(95% CI, 0.63 – 0.80) and SEDAN score was 0.65 (95% CI, 0.61 – 0.79) compared to the RICH score for s ICH. CONCLUSIONS: The Thrive score performed the best for predicting sICH over the SEDAN and RICH scores. Further utility of these scores to exclude s ICH post tPA for stroke needs a prospective study. CLINICAL IMPLICATIONS: Ultimately, determining the patients at highest risk for intracranial hemorrhage conversion after tPA is crucial to better patient outcomes. Several scoring scales have been created in order to determine which patients are at highest risk. Determining the most useful scoring scale to stratify the risk of ICH may help avoid a 24 hour follow up scan. Avoiding a 24 hour follow up scan could reduce healthcare cost, reduce radiation exposure, and reduce utilization of healthcare resources. DISCLOSURES: no disclosure on file for Zunair Afghani; No relevant relationships by Nitin Agrawal, source=Web Response No relevant relationships by Shekhar Ghamande, source=Web Response No relevant relationships by Conner Moslander, source=Web Response No relevant relationships by Jennifer Rasmussen-Winkler, source=Web Response No relevant relationships by Alfredo Vazquez Sandoval, source=Web Response No relevant relationships by Heath White, source=Web Response

Risk factors for intracerebral hemorrhage in patients with COVID-19.

Intracerebral hemorrhage (ICH) can be a devastating complication of coronavirus disease (COVID-19). We aimed to assess risk factors associated with ICH in this population. We performed a retrospective cohort study of adult patients admitted to NYU Langone Health system between March 1 and April 27 2020 with a positive nasopharyngeal swab polymerase chain reaction test result and presence of primary nontraumatic intracranial hemorrhage or hemorrhagic conversion of ischemic stroke on neuroimaging. Patients with intracranial procedures, malignancy, or vascular malformation were excluded. We used regression models to estimate odds ratios and 95% confidence intervals (OR, 95% CI) of the association between ICH and covariates. We also used regression models to determine association between ICH and mortality. Among 3824 patients admitted with COVID-19, 755 patients had neuroimaging and 416 patients were identified after exclusion criteria were applied. The mean (standard deviation) age was 69.3 (16.2), 35.8% were women, and 34.9% were on therapeutic anticoagulation. ICH occurred in 33 (7.9%) patients. Older age, non-Caucasian race, respiratory failure requiring mechanical ventilation, and therapeutic anticoagulation were associated with ICH on univariate analysis (p < 0.01 for each variable). In adjusted regression models, anticoagulation use was associated with a five-fold increased risk of ICH (OR 5.26, 95% CI 2.33–12.24, p < 0.001). ICH was associated with increased mortality (adjusted OR 2.6, 95 % CI 1.2–5.9). Anticoagulation use is associated with increased risk of ICH in patients with COVID-19. Further investigation is required to elucidate underlying mechanisms and prevention strategies in this population.Electronic supplementary materialThe online version of this article (10.1007/s11239-020-02288-0) contains supplementary material, which is available to authorized users.

Of Equestrians and Endocarditis

an 80-year old female was transferred from an outside hospital for concerns of a mitral valve vegetation and sepsis. Her past medical history included untreated chronic lymphocytic leukemia (CLL) and atrial fibrillation on warfarin therapy. The patient was otherwise very active and enjoyed daily rides on her horses. She initially presented with altered mental status and was found to be in septic shock with respiratory failure requiring intubation. Initial head CT showed an ischemic stroke in the bilateral frontal lobes. Echocardiogram showed a large mitral valve vegetation. A repeat CT of her head obtained for clinical decline revealed hemorrhagic conversion of her ischemic stroke. She began to have seizure activity that was treated with Keppra. Blood cultures grew Streptococcus zooepidemicus, and she was subsequently transferred to our tertiary medical center for increased level of care.

Letter: Thrombotic Neurovascular Disease in COVID-19 Patients.

Letter: Thrombotic Neurovascular Disease in COVID-19 Patients.

Cerebral ischemic and hemorrhagic complications of coronavirus disease 2019.

BackgroundThe coronavirus disease 2019 is associated with neurological manifestations including stroke.ObjectivesWe present a case series of coronavirus disease 2019 patients from two institutions with acute cerebrovascular pathologies. In addition, we present a pooled analysis of published data on large vessel occlusion in the setting of coronavirus disease 2019 and a concise summary of the pathophysiology of acute cerebrovascular disease in the setting of coronavirus disease 2019.MethodsA retrospective study across two institutions was conducted between 20 March 2020 and 20 May 2020, for patients developing acute cerebrovascular disease and diagnosed with coronavirus disease 2019. We performed a literature review using the PubMed search engine.ResultsThe total sample size was 22 patients. The mean age was 59.5 years, and 12 patients were female. The cerebrovascular pathologies were 17 cases of acute ischemic stroke, 3 cases of aneurysm rupture, and 2 cases of sinus thrombosis. Of the stroke and sinus thrombosis patients, the mean National Institute of Health Stroke Scale was 13.8 ± 8.0, and 16 (84.2%) patients underwent a mechanical thrombectomy procedure. A favorable thrombolysis in cerebral infarction score was achieved in all patients. Of the 16 patients that underwent a mechanical thrombectomy, the mortality incidence was five (31.3%). Of all patients (22), three (13.6%) patients developed hemorrhagic conversion requiring decompressive surgery. Eleven (50%) patients had a poor functional status (modified Rankin Score 3–6) at discharge, and the total mortality incidence was eight (36.4%).ConclusionsDespite timely intervention and favorable reperfusion, the mortality rate in coronavirus disease 2019 patients with large vessel occlusion was high in our series and in the pooled analysis. Notable features were younger age group, involvement of both the arterial and venous vasculature, multivessel involvement, and complicated procedures due to the clot consistency and burden.

Results From a Prospective Real-World Multicenter Clinical Practice of CAS Using the CGuard Embolic Prevention System: The IRONGUARD 2 Study

To evaluate periprocedural, 30-day, and 12-month outcomes in a prospective series of patients submitted to protected CAS with the CGuard Embolic Prevention System (EPS). From January 2017 to June 2019 a physician-initiated prospective multispecialty, multicenter study was initiated enrolling consecutive patients admitted for protected carotid artery stenting and treated using the CGuard EPS in twelve Italian centers. Primary end points were technical and procedural success, immediate (24 hours) and postprocedural (1-30 days) major and minor stroke, transient ischemic attack (TIA), and death rates. Secondary end points were 12-month neurologic adverse events, acute myocardial infarction (AMI), and external carotid artery occlusion rates. Seven hundred thirty-three patients (73.03 ± 7.84 years of age; 516 male) were enrolled. Mean carotid stenosis was 80.13 ± 8.51% (range, 50%-99%). Symptoms were present in 131 patients (17.87%): 96 TIAs, 23 minor strokes, and 12 major strokes. An embolic protection device was used in 731 (99.72%) cases: distal filter in 593 (80.9%) and proximal occlusion in 138 (18.82%). Procedural success was 100%, technical success was achieved in all but one patient (99.86%). At 24 hours, one patient died due to a hemorrhagic conversion after urgent carotid artery stenting procedure performed for unstable symptoms. Two minor strokes, 6 TIAs, and 1 AMI occurred before hospital discharge. External carotid artery occlusion was evident in eight patients (1.09%). At 30 days, the rate of new averse cardiac and cerebrovascular adverse event was 0.81%: three new neurologic events (2 TIAs, and 1 minor stroke); and three nonfatal AMI. Therefore, up to 30 days, the cumulative rates of death and stroke were 0.13% and 0.54%, respectively. Our analysis suggests that use of the CGuard-EPS in routine clinical practice was associated with an extremely low occurrence of adverse neurologic events in a nonselected patients’ population.

SAT-468 Anticoagulation Conundrum: A Case Of Embolic Stroke Due To Thyrotoxic Atrial Fibrillation

Background: Thyrotoxicosis is not incorporated into any of the atrial fibrillation (AF) CVA risk stratification methods, including CHADS2VASc, as neither the American College of Cardiology/American Heart Association nor the American College of Chest Physicians view it as an independent risk factor of CVA. However, the literature has reported numerous cases of patients with thyrotoxic AF and low CHADS2VASc scores who developed CVA. It is unclear which patients with thyrotoxic AF would benefit from prophylactic anticoagulation (AC). Clinical Case: A 50-year-old male without past medical history presented for palpitations. He was found to be in AF with rapid ventricular rate. Labs revealed thyrotoxicosis (TSH <0.010 [RR 0.34-5.6 μIU/mL], FT4 3.57 [RR 0.61-1.64 ng/dL], FT3 5.26 [RR 2.5-4.5 pg/mL], and TSI negative). He was started on methimazole but no AC, as his CHADS2VASc score was 0. A few hours after admission, he developed a right-sided facial droop and weakness & aphasia. CT head showed acute left MCA infarct. CTA head/neck revealed occlusive embolus in the distal left M1 segment. He underwent IR-guided embolectomy and received intra-arterial tPA. Echocardiogram did not show thrombi or atrial level shunt but showed right atrial dilation. After extensive work-up, etiology of CVA was determined most likely a cardioembolic source due to thyrotoxic AF. Patient was treated with PTU and steroids initially for two days due to recent contrast exposure (CTA and embolectomy) and poor neurologic status, in order to obtain the added benefit of decreased T4 to T3 peripheral conversion. Patient was started on AC two weeks after his CVA (given initial risk of hemorrhagic conversion due to large CVA burden), at which time his weakness and aphasia were slowly improving, but he remained with significant neurologic deficits. Discussion: The current thought that thyrotoxicosis is not an independent risk factor of CVA in patients with AF has led to recommendations against prophylactic AC for this specific group. Although recent research has suggested that patients with thyrotoxic AF are at a lower risk of CVA than patients with non-thyrotoxic AF, there have still been many reported cases of CVA in patients who have thyrotoxic AF but no other risk factors for CVA. This discrepancy in association between thyrotoxic AF and CVA needs to be clarified. Conclusion: This case of a middle-aged man with thyrotoxic AF who developed a debilitating CVA after being treated according to his CHADS2VASC score of 0 (he was not given prophylactic AC) mirrors multiple cases in the literature. It highlights the potential benefit of examining thyrotoxic patients with AF more closely in order to more effectively risk stratify them for CVA or further exploring the relationship between thyrotoxicosis and CVA. This may help to identify more patients who could benefit from AC and thus prevent devastating consequences of CVA.

Erratum. Predictors of 30-day hospital readmission after mechanical thrombectomy for acute ischemic stroke.

Objective The 30-day readmission rate is of increasing interest to hospital administrators and physicians, as it is used to evaluate hospital performance and is associated with increased healthcare expenditures. The estimated yearly cost to Medicare of readmissions is $17.4 billion. The Centers for Medicare and Medicaid Services therefore track unplanned 30-day readmissions and institute penalties against hospitals whose readmission rates exceed disease-specific national standards. One of the most important conditions with potential for improvement in cost-effective care is ischemic stroke, which affects 795,000 people in the United States and is a leading cause of death and disability. Recent widespread adoption of mechanical thrombectomy has revolutionized stroke care, requiring reassessment of readmission causes and costs in this population. Methods The authors retrospectively analyzed a prospectively maintained database of stroke patients and identified 561 patients who underwent mechanical thrombectomy between 2010 and 2019 at the authors' institution. Univariate and multivariate analyses were conducted to identify clinical variables and comorbidities related to 30-day readmissions in this patient population. Results Of the 561 patients, 85.6% (n = 480) survived their admission and were discharged from the hospital to home or rehabilitation, and 8.8% (n = 42/480) were readmitted within 30 days. The median time to readmission was 10.5 days (IQR 6.0-14.3). The most common reasons for readmission were infection (33.3%) and acute cardiac or cerebrovascular events (19% and 20%, respectively). Multivariate analysis showed that hypertension (p = 0.030; OR 2.72) and length of initial hospital stay (p = 0.040; OR 1.032) were significantly correlated with readmission within 30 days, while hemorrhagic conversion (grades 3 and 4) approached significance (p = 0.053; OR 2.23). Other factors, such as unfavorable outcome at discharge, history of coronary artery disease, and discharge destination, did not predict readmission. Conclusions The study data demonstrate that hypertension, length of hospital stay, and hemorrhagic conversion were predictors of 30-day hospital readmission in stroke patients after mechanical thrombectomy. Infection was the most common cause of 30-day readmission, followed by cardiac and cerebrovascular diagnoses. These results therefore may serve to identify patients within the stroke population who require increased surveillance following discharge to reduce complications and unplanned readmissions.

Stroke-Associated Pneumonia: A Retrospective Study of Risk Factors and Outcomes.

Pneumonia is the most common complication after stroke, but our knowledge on risk factors and predictors of stroke-associated pneumonia (SAP) is limited. We sought to evaluate the predictors and outcomes of SAP among acute ischemic stroke (AIS) hospitalizations. This is a cross-sectional study of the Nationwide Inpatient Sample database from the year 2003 to 2014. We identified adult hospitalizations with AIS using International Classification of Diseases, ninth revision, clinical modification (ICD-9-CM) codes. The SAP was identified by the presence of a secondary diagnosis of hospital-acquired pneumonia and ventilator-associated pneumonia. Multivariable survey logistic regression models were utilized to evaluate the predictors of SAP. Overall, 4,224,924 AIS hospitalizations were identified, of which 149,169 (3.53%) had SAP. The prevalence of SAP decreased from 3.72% in 2003 to 3.17% in 2014 (P<0.0001). Mortality [17.12% vs. 4.77%; adjusted odds ratio (aOR): 1.71; P<0.0001] and morbidity (22.53% vs. 3.28%; aOR: 1.86; P<0.0001) were markedly elevated in SAP group compare to non-SAP group. The significant risk factors of pneumonia among AIS hospitalization were nasogastric tube (aOR: 1.21; P=0.0179), noninvasive mechanical ventilation (aOR: 1.65; P<0.0001), invasive mechanical ventilation (aOR: 4.09; P<0.0001), length of stay between 1 to 2 weeks (aOR: 1.99; P<0.0001), >2 weeks (aOR: 3.90; P<0.0001), hemorrhagic conversion (aOR: 1.17; P=0.0002), and epilepsy (aOR: 1.09; P=0.0009). Other concurrent comorbidities which increased the risk of SAP among AIS patients were acquired immune deficiency syndrome (aOR: 1.88; P<0.0001), alcohol abuse (aOR: 1.60; P=0.0006), deficiency anemia (aOR: 1.26; P<0.0001), heart failure (aOR: 1.62; P<0.0001), pulmonary disease (aOR: 1.73; P<0.0001), diabetes (aOR: 1.29; P=0.0288), electrolyte disorders (aOR: 1.50; P<0.0001), paralysis (aOR: 1.22; P<0.0001), pulmonary circulation disorders (aOR: 1.22; P<0.0001), renal failure (aOR: 1.12; P<0.0001), coagulopathy (aOR: 1.13; P=0.0006), and weight loss (aOR: 1.39; P<0.0001). Our data underline the considerable epidemiological and prognostic impact of SAP in patients with AIS leading to higher mortality, morbidity, length of stay, and hospital cost despite advancements in care.

Challenges of Thrombolysis in a Developing Country: Characteristics and Outcomes in Peru

Background: The availability of intravenous tissue plasminogen activator (IV-tPA) remains limited worldwide, especially in low-income countries, where the burden of disability due to ischemic stroke is the highest. Aims: To evaluate outcomes and safety of IV-tPA at the only Peruvian reference institute for neurologic diseases. Methods: We conducted a prospective, observational study of stroke patients who received IV-tPA between 2009 and 2016. We assessed characteristics associated with good outcome (modified Rankine scale 0-2) at 3 months using a multivariate regression model; and factors correlated with clinical improvement (delta National Institute of Health Stroke Scale (NIHSS)) using linear regression. Results: Only 1.98% (39/1,1962) of patients presenting with ischemic stroke received IV-tPA. Nearly half (41%) were younger than 60 years, 56.4 % were men, and most strokes were cardioembolic (46.2%). The majority (64.1%) were treated within 3-4.5 hours. The median NIHSS on admission and discharge was 9 and 4, respectively; 42.1% of patients had an mRS of 0-1 at 3 months. Three patients (7.7%) developed hemorrhagic conversion, and 1 patient died (2.6%). Patients with good outcomes had lower pretreatment systolic blood pressure (138.9 versus 158.1 mm Hg, P < .007), fewer complications during hospitalization (5 versus 9 events, P < .001), shorter hospital stay (14 versus 21 days, P < .03) and, paradoxically, longer last known well -to-door times (148.3 versus 105 minutes, P < .0022). Clinical improvement was associated with shorter door-to-tPA times and obesity. Conclusions: Our findings indicate that IV-tPA has similar safety and outcomes compared to developed countries. All internal metrics (door-to-tPA, door-to-CT, and CT-to-tPA time) improved over time, highlighting areas for future implementation science studies to further expedite the administration of IV-tPA.

Hot Off the PRES: A Case Series on Posterior Reversible Encephalopathy Syndrome with Hemorrhagic Conversion Associated with Phenylephrine (2442)

Hot Off the PRES: A Case Series on Posterior Reversible Encephalopathy Syndrome with Hemorrhagic Conversion Associated with Phenylephrine (2442)

Lower LDL is Not Associated With Increased Risk of Hemorrhagic Conversion after Mechanical Thrombectomy (2808)

Lower LDL is Not Associated With Increased Risk of Hemorrhagic Conversion after Mechanical Thrombectomy (2808)

Predicting Death After Thrombectomy in the Treatment of Acute Stroke.

Introduction: Treatments for acute stroke have significantly improved in the past decade, with emergent thrombectomy emerging as the standard of care. Despite these advancements, death after successful thrombectomy continues to pose a significant problem. Identifying patients least likely to benefit from thrombectomy would improve use of a limited resource and management of patient expectations.Method: We retrospectively reviewed the medical records of patients who underwent emergent thrombectomy of either anterior or posterior circulation strokes between January 2012 and January 2017. Relevant patient clinical data was collected and analyzed in a multivariable regression with a primary outcome of death at 90 days.Results: A total of 134 patients underwent emergent endovascular thrombectomy during the study period; sufficient clinical data was available in 111 of the them. Of these, 42 patients died during the 90 day post-procedural period and 69 patients survived this period. The mean NIHSS score at presentation was 14.9 in surviving patients and 19.6 in non-surviving patients (p < 0.002). Surviving patients were less likely to have a history of cancer (4.4% vs. 26.2%, p < 0.002), achieved higher rates of revascularization (78.3% vs. 50.0%, p < 0.003), had a lower rate of hemorrhagic conversion (21.7% vs. 47.6%, p < 0.004), and experienced fewer technical complications during their treatment (7.4% vs. 26.2%, p < 0.01). Overall, there were 16 intraprocedural complications and no procedural deaths.Conclusion: As emergent thrombectomy for the treatment of acute stroke becomes more prevalent, appropriate patient selection will be crucial in the utilization of a limited and costly intervention. Death within 90 days after thrombectomy appears to be more prevalent among patients with higher NIHSS at presentation, those with postprocedural hemorrhage or intraprocedural complications, and those with a history of cancer.

Acute Anticoagulation after Ischemic Stroke in Patients with Left Ventricular Assist Devices

Despite reductions in major adverse events with the latest generation of left ventricular assist devices (LVADs), the incidence of stroke remains high. The timing of anticoagulation resumption is controversial. We aim to explore practices of anticoagulation management following ischemic stroke in LVAD patients and identify optimal strategies. We retrospectively analyzed our LVAD database between 11/2012 and 5/2018. Patients who suffered ischemic stroke were categorized into 3 groups based on the timing of anticoagulation resumption post-stroke: anticoagulation immediately continued (A), held 1-4 days (B), held >4 days (C). Primary outcome events included recurrent ischemic stroke or TIA, pump thrombosis, systemic thrombosis, and intracranial or extracranial bleeding within 90 days. Descriptive and nonparametric survival analyses were performed. Of the 38 patients identified as having an ischemic stroke, 22 experienced 37 primary outcomes including 5 recurrent ischemic strokes/TIAs, 3 pump thromboses, 15 systemic embolic events, 9 intracranial and 5 systemic hemorrhages. We found no significant association between timing of anticoagulation resumption and incidence of subsequent ischemic events (Group A= 39%, B= 22%, C= 17%) or intracranial bleeding (Group A= 17%, B= 33%, C= 33%). Kaplan-Meier survival free of a primary outcome for all patients was 65%, 56% and 50% at 7, 14 and 30 days post ischemic stroke, respectively. There was no association between survival and timing of anticoagulation, sex, LVAD type or placement before vs after 2014. We found a high rate of early outcomes after ischemic stroke in LVAD patients, with no evidence of increased risk with continued anticoagulation. Accepting the limitations of a retrospective study, these data suggest that anticoagulation may not need to be held acutely to prevent hemorrhagic conversion. Risk factors for these post ischemic stroke outcomes however were not identified. Further research is needed to identify approaches to decrease these secondary complications.

Intracranial hemorrhage type and same-admission mortality in patients with left ventricular assist devices

ObjectivesLeft ventricular assist devices (LVAD) provide mechanical circulatory support for patients with advanced heart failure. Intracranial hemorrhage in this population represent a significant management challenge. The objective of this study is to report our initial experience on same-admission outcomes with LVAD patients that presented with various types of intracranial hemorrhage (ICH). Patients and MethodsA retrospective review of a large volume center over a two-year period was performed. LVAD patients with ICH requiring a neurosurgical consultation were identified. Hemorrhage type, interventions, discharge disposition and cause of death were recorded. Results27 LVAD patients with ICH received a neurosurgical consultation. The average INR at the time of ICH was 2.7 (1.0–8.8). Hemorrhage types seen were lobar (10/27, 37 %), SAH (5/27, 19 %), SDH (4/27, 15 %), cerebellar ICH (3/27, 11 %), multiple ICH (3/27, 11 %), and hemorrhagic conversion (2/27, 7 %). The overall mortality rate was 48.2 % (13/27), with the highest mortality being in those patients who had multiple ICH at the time of presentation (3/3, 100 %). The majority of patients with ICH (85.2 %) were non-operative. Lobar IPH was <3 cm in 80 % (8/10) of these, and 6/8 (75 %) ultimately died. 11 %(3/27) received surgical intervention. Of these, 67 % ultimately withdrew care. 77 % (10/13) of patients died as a result of the ICH. 80 % of patients with SAH were ultimately discharged home. ConclusionsPatients with a LVAD and ICH have a high rate of same-admission mortality (48 %). Hemorrhage location, intra-axial or extra-axial, resulted in patients being a risk for death secondary to either the hemorrhage itself or pump thrombosis, respectively.

Assessment of the Functional Status of Patients with Ischaemic Stroke Receiving Thrombolytic Treatment

Introduction. Intravenous thrombolysis is a gold standard in the treatment of acute ischaemic stroke. It causes reperfusion in the region of ischaemia and as a result it has a positive effect on functional outcomes of patients. The sooner this treatment is introduced the higher efficacy can be expected.Aim. The study objective was to assess the functional status of patients with ischaemic stroke, undergoing thrombolytic treatment and the incidence of thrombolysis complications.Material and Methods. Retrospective studies were conducted on a group of 109 patients hospitalised due to ischaemic cerebral stroke and qualified for thrombolytic treatment. The functional status was assessed with the use of the modified Rankin Scale and National Institutes of Health Stroke Scales on admission and discharge day. The study group included 55 males and 54 females (respectively: 50.5% and 49.5% of the total study population). The subject age was between 32 and 96 years, with the mean age of 69.8.Results. The average time between the onset of symptoms and initiation of thrombolytic treatment was 182 minutes. The National Institutes of Health Stroke Scale at the moment of qualification for treatment was 10.11 points, and the Rankin Scale was 2.88 points. On the day of discharge, the values were 5.81 and 2.05, respectively. A statistically significant (p &lt; 0.0001) improvement in the functional status was observed in the group of patients who had no intra cerebral haemorrhage after thrombolysis. The most common complication of thrombolytic treatment was haemorrhagic transformation of the ischaemic stroke focus — 27 cases (24.77%). Death occurred in 9 subjects (8.26% of total), including 6 cases in males (10.91% of males) and was related to haemorrhagic transformation of the ischaemic stroke focus (p = 0.000).Conclusions. The implemented treatment of stroke resulted in improvement of the functional status. The most frequent complication was haemorrhagic conversion of stroke. (JNNN 2020;9(1):12–19)

Infarct Core Reliability by CT Perfusion is a Time-Dependent Phenomenon.

In the setting of an extended time window for endovascular treatment (EVT) for acute stroke patients, computed tomography perfusion (CTP) has become a major tool in patient selection. However, there are some data suggesting that the initial ischemic core may be overestimated by CTP depending on stroke onset time. This study aims to evaluate possible predictors of overestimation of infarct core by CTP. We studied all consecutive stroke patients undergoing EVT during 1 year who underwent CTP at admission and had a successful recanalization. Admission infarct core was measured on cerebral blood volume maps generated using the Intellispace Portal (Philips Healthcare, Best, the Netherlands) and final infarct was measured on noncontrast follow-up computed tomography at 24 hours. We defined overestimation of the infarct core as initial core minus final infarct >10 mL. Out of 107 patients undergoing EVT in the study period, 60 were anterior circulation and had CTP done at our institute, and of them 31 were compatible with the inclusion criteria (known time of onset, no hemorrhagic conversion, and good recanalization). Median National Institute of Health Stroke Scale on admission was 13. Median time from symptoms to CTP was 148 minutes. Seventeen patients were found to have overestimation of the infarct core. Logistic regression analyses showed time from symptom onset to CTP to be inversely related to overestimation with a cutoff of 170 minutes (sensitivity 94% and specificity 43%). Over estimation of the infarct core by CTP in patients undergoing EVT is time dependent and so CTP results among early arrivers should be interpreted cautiously.

Risk factors and outcomes of intravenous tissue plasminogen activator and endovascular thrombectomy utilization amongst pediatrics acute ischemic stroke.

Pediatric stroke is a debilitating disease. There are several risk factors predisposing children to this life-threatening disease. Although, published literature estimates a relatively high incidence of pediatric stroke, treatment guidelines on intravenous tissue plasminogen activator and endovascular thrombectomy utilization remain a dilemma. There is a lack of large population-based studies and clinical trials evaluating the efficacy and safety outcomes associated with these treatments in this unique population. We sought to determine the prevalence of risk factors, concurrent utilization of intravenous tissue plasminogen activator and endovascular thrombectomy, and associated outcomes in pediatric stroke hospitalizations. We performed a retrospective analysis of the Nationwide Inpatient Sample data (2003-2014) in pediatric (1-21 years of age) acute ischemic stroke hospitalizations using ICD-9-CM codes. The multivariable survey logistic regression model was weighted to account for sampling strategy, evaluate predictors of hemorrhagic conversion, and treatment outcomes (mortality, morbidity, and discharge disposition) amongst pediatric stroke hospitalizations. In this analysis, 9109 patients between 1 and 21 years of age were admitted during 2003-2014 for acute ischemic stroke. Of these 9109 patients, 119 (1.30%) received endovascular thrombectomy alone, 256 (2.82%) intravenous recombinant tissue plasminogen activator, and 69 (0.75%) both endovascular thrombectomy and intravenous recombinant tissue plasminogen activator. We found overall high prevalence of conditions like epilepsy (19.59%), atrial septal defect (11.76%), sickle cell disease (8.63%), and moyamoya disease (5.41%) in pediatric acute ischemic stroke patients. Unadjusted analysis showed high prevalence of all-cause in-hospital mortality in combined endovascular thrombectomy and intravenous recombinant tissue plasminogen activator utilization group, and higher prevalence of hemorrhagic conversion and morbidity in endovascular thrombectomy utilization group compared to other groups (p < 0.0001). Multivariate adjusted analysis showed that children with endovascular thrombectomy utilization (aOR: 19.19; 95% CI: 2.50-147.29, p = 0.005), intravenous recombinant tissue plasminogen activator utilization (aOR: 8.85; 95% CI: 1.92-40.76, p = 0.005), and both (endovascular thrombectomy and intravenous recombinant tissue plasminogen activator) utilization (aOR: 7.55; 95% CI: 1.16-49.31, p = 0.035) had higher odds of hemorrhagic conversion compared to no-treatment group. We found various risk factors associated with pediatric stroke. The early identification can be useful to formulate preventive strategies and influence the incidence of pediatric stroke. Our study results showed that use of intravenous recombinant tissue plasminogen activator and endovascular thrombectomy increase risk of mortality and hemorrhagic conversion, but we suggest to have more clinical studies to evaluate the idea candidates for utilization of intravenous recombinant tissue plasminogen activator and endovascular thrombectomy based on risk: benefit ratio.